Alcohol, Anxiety, and Depressive Disorders

Alcoholics frequently experience episodes of intense depression and/or severe anxiety. Depressed or anxious alcohol-dependent people often believe that they drink to relieve symptoms of sadness or nervousness. However, research does not unanimously support the prior existence of severe depressive or anxiety disorders as a usual cause of alcoholism. A review of recent literature (from family studies, prospective investigations, and studies of children of alcoholics) on the complex interaction between alcohol dependence and independent anxiety/depressive disorders reveals that if an association between alcoholism and anxiety/depressive disorders does exist, it likely operates in a relatively small subgroup of alcoholics at the same time. Psychological symptoms may carry a worse prognosis for alcohol-related problems, and these symptoms must be addressed early in alcoholism treatment.

T he relationship between alcohol to require treatment. When depressed or consequence of the person's consump use disorders and psychiatric anxious alcoholdependent people are tion of high doses of alcohol (i.e., the symptoms is both clinically im asked their opinions about cause and complaints are alcohol induced), then portant and very complex (Brady and effect, they often reply that they believe the symptoms are likely to improve Lydiard 1993). As a typical depressant, they drink in order to cope with their fairly quickly with abstinence. In this alcohol affects the brain in many ways, symptoms of sadness or nervousness. case, it is uncertain whether the longer and it is likely that high doses will cause Two recent reviews, however, indi term treatment of alcoholism requires feelings of sadness (i.e., depression) cate that research does not unanimously additional aggressive therapies aimed during intoxication that evolve into support the prior existence of severe at treating underlying depressive or feelings of nervousness (i.e., anxiety) depressive or anxiety disorders as a anxiety disorders. during the subsequent hangover and usual cause of alcoholism (Allan 1995; This article briefly reviews some of withdrawal. The greater the amounts of Schuckit and Hesselbrock 1994). In this the recent literature on the complex in alcohol consumed and the more regular article, the term "depressive disorders" teraction between alcohol dependence the intake, the more likely a person will refers to an episode of major depressive and the longer lasting anxiety or depres be to develop temporary anxiety and disorder that significantly interferes sive disorders. The interactions between depressive symptoms. As consumption with a person's functioning over many alcoholism and these disorders are eval increases even more, these symptoms weeks or months, and "anxiety disor uated by posing a series of questions, also are likely to intensify.
ders" refers to any of a number of It is, therefore, not surprising that serious and typically lifelong anxiety MARC A. SCHUCKIT, M.D., is a profes more than one out of every three alco conditions (for further detail, see glos sor of psychiatry at the University of holics has experienced episodes of in sary, p. 86). Of course, when an alcohol California-San Diego, School of tense depression and/or severe anxiety dependent person complains of severe Medicine, and director of the Alcohol (Cox et al. 1990;Wilson 1988 What are the immediate clinical implications of coexisting depressive and anxiety states among alcoholics? As many as 80 percent of alcoholics report periods of sadness in their medi cal histories, with approximately one out of three alcoholdependent men and women having experienced a severe depression that lasted for at least sev eral weeks and interfered with his or her functioning (Brown and Schuckit 1988;Winokur 1983). Similarly, the majority of alcoholics admit to experi encing periods of nervousness, includ ing at least 40 percent who have had one or more intense panic attacks char acterized by a brief episode of palpita tions and shortness of breath (Kushner et al. 1990). An alcoholdependent person who demonstrates such psychological symp toms needs more intense intervention and support than may otherwise be pro vided, and if not appropriately treated, the symptoms may carry a worse prog nosis for alcoholrelated problems. High levels of depression are especially wor thy of concern, because the risk of death by suicide among alcoholics, estimated to be 10 percent or higher, may be most acute during these depressed states.
Once a person becomes deeply de pressed, regardless of the cause, he or she may need to be hospitalized and provided with the appropriate precau tions against suicide. These steps should be considered even if the patient's de pressive disorder is a relatively short lived alcoholinduced state. Practitioners can counteract their patients' depressive symptoms by providing education and counseling as well as by reassuring the patients of the high likelihood that they will recover from their depressions. Sim ilarly, an alcoholic who experiences repeated panic attacks or other anxiety symptoms requires intervention for the anxiety, regardless of the cause. Alco holics who experience high levels of anxiety or nervousness, including panic attacks, will likely benefit from edu cation and reassurance as well as from behavioral therapies aimed at increas ing levels of relaxation.
Most clinicians and researchers would agree that alcoholics experience high rates of anxiety and depressive symptoms and that these problems must be addressed early in treatment (Brady and Lydiard 1993). Increased debate, however, has focused on whether the depressive and anxiety disorders pre cipitated the patients' alcoholism-in which case, longer term intensive treat ments aimed at these psychiatric con ditions might be required to ensure the optimum chance of recovery from al coholism. Disagreement also exists about whether longer term independent treatment for depressive or anxiety diag noses is required for the alcoholic per son to achieve a normal level of life functioning. As previously mentioned, it is possible that many depressed or anxious alcoholics demonstrate mood or nervousness conditions caused by intoxication or withdrawal from alco hol; these psychiatric states are likely to improve markedly during the first several weeks to 1 month of abstinence. Thus, longterm psychiatric treatment does not appear to be required for alcoholinduced psychiatric conditions to be resolved (Brown and Schuckit 1988;Schuckit and Hesselbrock 1994).

What evidence exists to support the conclusion that alcoholics have sig nificantly higherthanexpected rates of longterm major depressive or anxiety disorders? Certain theories
give rise to the expectation that al coholics might have high rates of longterm, independent anxiety and depressive disorders (Wilson 1988). For example, many psychological theories developed during the early and mid20th century proposed that people used high doses of alcohol to cope with the inappropriate resolution of more primitive phases of personality development, problems with sexuality or sex roles, and feelings of inadequacy or powerlessness (Vaillant 1995). Per haps as a result of the influence of these theories, psychotherapists fre quently reported deepseated emotional difficulties or persisting psychiatric symptoms in alcoholics, even when alcoholdependent people were sober.
As recently reviewed in the litera ture, some interesting data also support a possible relationship between long standing anxiety or depressive disorders and alcoholism (Kushner et al. 1990;Kushner 1996). The findings include a higherthanexpected rate of anxiety or depressive symptoms among alcoholics or their relatives, and several studies indicate a possible increased rate of alcoholism among people presenting for treatment for depressive or anxiety diagnoses or among their relatives (Cox et al. 1990;Kushner 1996;Mason et al. 1996). The most consistent results re late to manic episodes, wherein manic depressive patients show a small but significant increased risk for alcohol ism (Winokur et al. 1993). Other data also suggest a greaterthanchance as sociation between panic disorder (and perhaps social phobia) and alcoholism (Cowley 1992;Cox et al. 1990;Kushner 1996). These studies, however, do not clearly establish the intensity of the relationship between these psychiatric disorders and alcoholism (e.g., what percentage of alcoholics have indepen dent anxiety disorders?), and the asso ciation of alcoholism to other mood or anxiety disorders is even less clear.
Although these studies raise impor tant questions, researchers cannot draw definitive conclusions about the asso ciation between alcoholism and psy chiatric disorders for a number of reasons. The major problem encoun tered in these studies involved the use of research methods that failed to address several important issues that might have explained the observed re lationships (Allan 1995;Schuckit and Hesselbrock 1994). Specifically, some studies focused on drinking patterns rather than on alcohol dependence or described mood/anxiety symptoms rather than true psychiatric disorders. The distinction is important, because symptoms might be only temporary, whereas true psychiatric disorders are likely to require longterm and more intensive treatments, including psy chotherapy and medication. Thus, few of the investigations offered assurance that an alcoholic or alcoholic's relative actually had a longterm psychiatric syndrome rather than a temporary alcoholinduced condition.
In addition, researchers have con sidered whether alcoholism and some psychiatric disorders may have a genetic association-that is, whether they may be inherited together. Similar to alcohol ism, most psychiatric disorders run in families and are genetically influenced. Thus, in reporting the rates of alcohol ism or depressive/anxiety disorders among relatives of subjects, some stud ies may have overlooked the presence of both types of illnesses in the initial subjects or in the parents of the subjects' relatives. The apparent association be tween alcoholism and these psychiatric syndromes may actually result from the marriages between individuals with the two separate disorders rather than a reflection of a single disorder in the family (i.e., the disorders would ap pear associated when in fact they occur independently in the same family). (For further information on the genetic asso ciation of alcoholism and psychiatric disorders, see the articles by Merikan gas et al. and Woody, pp. 100-106 and pp. 76-80, respectively.) Several separate lines of evidence cast doubt on the possibility that high proportions of alcoholics have severe, longterm depressive or anxiety disor ders. These research approaches lead to three conclusions, discussed below.
1. Children of alcoholics (COA's) do not have an increased risk for major depressive or anxiety disorders. Al cohol dependence has been shown to be genetically influenced and to run in families (Schuckit and Smith 1996). The disorder often develops when individuals are in either their twenties or thirties. Similarly, major anxiety disorders usually are apparent before age 30, and although major depressive disorders often have a later onset, they too are frequently observed before age 30. Therefore, if COA's-people who carry a fourfold increased risk for the future development of alcoholism-often developed their alcohol depen dence as a consequence of preexisting major psychiatric disorders, longterm studies of these young men and women should demonstrate a high rate of psy chiatric syndromes before the onset of alcohol dependence.
Indeed, several disorders are more likely to be observed in COA's than in control groups, including conduct problems, such as difficulties with dis cipline at home or in school (Schuckit and Hesselbrock 1994). As cited in our recent review, however, an evaluation by Hill and colleagues 1 of 95 COA's and control subjects at ages 8 to 18 showed no evidence of increased rates for depressive or anxiety disorders in the offspring of alcoholics (Schuckit and Hesselbrock 1994). That same re view cited a second study of 283 COA's and control subjects by Reich and col leagues 1 that also reported no evidence for an increase in depressive disorders in COA's, although evidence indicated a possible higher rate of anxiety symp toms. However, a prospective followup of 204 Danish COA's and control sub jects by Knop and colleagues 1 dem onstrated no differences between the 2 groups by age 20 with respect to either depressive or anxiety disorders. A sub sequent followup of the Danish popu lation revealed higher levels of anxiety disorders but not depressive episodes for the offspring of alcoholic parents, although by that age some of the symp tomatology might already have resulted from high levels of alcohol or other drug (AOD) intake.
Schuckit and colleagues have stud ied the rates of psychiatric disorders in COA's from a variety of perspectives. First, as cited in a review article, a sur vey of 18 to 25yearold male students and staff at a university revealed no higher rates of depressive or anxiety disorders among COA's compared with control subjects, a finding con firmed by a more intensive evalua tion of men in a laboratory setting (Schuckit 1994). Second, the re searchers conducted followup on 453 sons of alcoholics and control 1 For reviews of studies not cited in the refer ence list, see Schuckit and Hesselbrock 1994. subjects who were tested in the lab oratory at approximately age 20, thereby gathering data regarding the development of depressive, anxiety, and alcoholuse disorders during the subsequent decade (Schuckit and Smith 1996). In this followup study, although the sons of alcoholics were three times more likely to develop alcohol abuse or dependence, they showed no higher rates of major de pressive disorders or major anxiety disorders during the followup period.
Only one notable study of COA's has demonstrated a higherthanexpected risk for these major psychiatric disor ders. As cited in a recent review, this in vestigation by Mathew and colleagues 1 evaluated subjects at a relatively older age (i.e., at approximately age 40), and the research methodology did not ade quately control for the possibility that the symptoms exhibited by these middle age COA's might have resulted from their higher alcoholism rates (Schuckit and Hesselbrock 1994). However, as pointed out by Kushner (1996), larger studies of COA's who have passed the age of risk for most disorders will need to be conducted before final con clusions can be drawn.

Most prospective studies do not
show higher rates of depressive or anxiety disorders in people who sub sequently develop alcoholism. Vail lant (1995) has conducted a 40year followup of 2 samples, one including more than 200 college men and the other including more than 450 blue collar boys who were ages 11 to 16 at the time of the original study. Infor mation was available on the subjects' psychiatric symptoms and AODuse patterns and problems, both at the time of enrollment into the study and at sev eral points during the longterm follow up. Despite finding that rates of alcohol abuse or dependence were relatively high in both samples, the researchers saw no evidence that preexisting de pressive or anxiety disorders occurred at higher rates among those subjects who later developed alcoholism.
A recent review revealed similar results from other studies (Schuckit and Hesselbrock 1994). For example, a 10year followup of young men and women who originally had been studied during their midteens by Ensminger and colleagues 1 showed no close asso ciation between preexisting anxiety symptoms and AODuse patterns in either sex. Similarly, in a study by Kammeier and colleagues, 1 there was little evidence that preexisting psychi atric symptoms measured by a standard personality test predicted later alco holism. From another perspective, as reported by Hagnell and Tunving, 1 personal interviews conducted with more than 99 percent of the 950 males age 20 and older in a Swedish town revealed that alcoholics had a rate no higher than that of the general popu lation for "neuroses," a term likely to have encompassed both depressive and anxiety disorders. Also, an 18year followup of 80 children who had ex perienced severe depressive episodes earlier in life revealed no evidence of an increased risk for alcoholism dur ing the followup period (Harrington et al. 1990). Finally, Schuckit's re search group followed 239 alcoholic men 1 year after they received alco holism treatment, and the data re vealed no significantly increased rates of major depressive or anxiety disor ders (Schuckit and Hesselbrock 1994). It is possible, however, that some of these studies might have excluded subjects with more severe anxiety or depressive disorders from the original samples, and consequently more work in this area is required (Kushner 1996).

When proper controls are used, some studies do not reveal high rates of longterm major depressive or anxi ety disorders in relatives of alcoholics.
A recent report from the Collaborative Study on the Genetics of Alcoholism (COGA) focused on 591 personally interviewed relatives of alcohol dependent men and women . After controlling for po tential alcoholinduced anxiety condi tions in relatives, the lifetime risk for any major anxiety disorder in the male and female relatives of alcoholics was between 6.7 and 6.9 percent, rates not different from those expected in the general population. Neither male nor female relatives showed increased risks for obsessivecompulsive disorder, social phobia, panic disorder, and/or agoraphobia. A preliminary evaluation of the lifetime rates of major depres sive disorders in 2,409 interviewed re latives of alcoholics revealed a rate of 17.5 percent, a figure that was almost identical to the rate observed in con trol families.
Similar results have been generated from some, but not all, studies of alco holism in relatives of patients with severe anxiety disorders. For example, an evaluation of 1,047 adult relatives of 193 subjects with severe anxiety dis orders revealed no increased risk of alcoholism among the relatives, with the exception of the relatives of those patients who had exceptionally early onsets of their psychiatric disorders (Goldstein et al. 1994). Nor did a re view of several recent studies by Fyer and colleagues 1 and Noyes and col leagues 1 reveal high rates of alcohol ism in relatives of people with social phobia or other anxiety disorders (Schuckit and Hesselbrock 1994).
Consistent with the generally nega tive results of these family type studies are the conclusions drawn from a recent study of 1,030 femalefemale twin pairs (Kendler et al. 1995). The researchers concluded that the genetic influences important in alcoholism appear to be relatively specific for that disorder and did not significantly alter the risk for additional psychiatric disorders, in cluding major depression and major anxiety disorders. Another twin study by Mullin and colleagues 1 showed no increased risk for anxiety disorders in identical twins of alcoholics with the exception of conditions (e.g., anxiety) that might have resulted from the al coholism in the person's twin.
It is important to remember, how ever, that certain studies show some overlap among depressive, anxiety, and alcoholic disorders in the same family. Many of these studies are mentioned in the Schuckit and Hesselbrock review, including the work by Merikangas and colleagues (1985). Other such studies are highlighted in the review by Brady and Lydiard (1993).
In summary, none of the three types of studies conducted (i.e., family stud ies, prospective investigations, and studies involving COA's) proves an absence of a relationship between long term anxiety or depressive disorders and alcoholism. As briefly discussed earlier in this article, the family studies are far from definitive because of dif ficulties in the methodologies used. It is also important to remember that some studies indicate a potential relationship between alcoholism and anxiety/ depressive disorders. In addition, alco holism and these psychiatric disorders may operate together within some families, or individual instances may occur whereby a person develops alco holism as a direct reflection of a preex isting psychiatric syndrome.
Conversely, the three types of stud ies highlighted in this section indicate that if an association between alcohol ism and anxiety/depressive disorders does exist, it is likely to operate in a relatively small subgroup of alcoholics. More research is required before an adequate answer can be produced.
What are the treatment implications of these findings? The first conclu sion to be drawn from this review is that many alcoholdependent people are likely to present with depressive or anxiety symptoms that must be rec ognized and addressed. These prob lems contribute to an increased risk for suicide attempts, may be associated with more intense withdrawal symp toms, and may contribute to alcohol ism relapse. Appropriate interventions for these psychiatric symptoms include forms of supportive psychotherapy, such as counseling or crisis interven tion, and behavioral treatment, such as relaxation techniques and desensi tization (Schuckit 1995).
Second, the possibility that a longer term anxiety or depressive disorder exists in an alcoholic must always be considered. Perhaps 10 percent of men and 10 to 20 percent of women in the general population develop severe anxi ety or depressive disorders (Regier et al. 1990); therefore, it would be logical to expect that at least this proportion of alcoholics also would have similar syn dromes. Identifying when an alcohol dependent person has an independent or longterm major anxiety or depres sive disorder requires gathering a careful patient history that searches for evidence of severe psychiatric symp toms either before the onset of severe alcoholrelated problems or during a subsequent period of extended absti nence. Similarly, all alcoholics evi dencing symptoms of severe depression or anxiety should be followed for ap proximately 1 month after abstinence to be certain that the depressive and anxiety symptoms are improving, be cause it is likely that severe symptoms remaining after abstinence for such a length of time may indicate a true in dependent depressive or anxiety disor der that requires longer term treatment.
However, treating most alcoholics' depressive symptoms might not require the use of antidepressant medications. Although one recent smallscale study presented some promising results using these medications (Mason et al. 1996), most research performed in subjects without evidence of a longterm de pressive disorder independent of their heavy drinking has found that antide pressant medications are unlikely to help the alcoholic maintain abstinence. These medications are not needed to help clear an alcoholinduced mood or depressive disorder. In fact, with absti nence the depressive symptoms are likely to improve in a shorter period of time than would be required for an anti depressant to take effect (Brown and Schuckit 1988;Powell et al. 1995).
Similarly, in the absence of clear evidence of a longterm major anxiety disorder that predates the onset of alco holism or that remains intense after an extended period of abstinence, few in dications exist for using medications related to anxiety for alcoholics. Panic attacks that are likely to develop during alcohol withdrawal are also likely to diminish in frequency and intensity on their own without medications (Schuckit and Hesselbrock 1994). Because little evidence exists of an increased risk for obsessivecompulsive disorder among alcoholics, pharmacological treatments aimed at this severe anxiety condition also are inappropriate in the absence of additional evidence of an independent anxiety syndrome. Although more data are needed, at least one study indicates that buspirone, a medication useful for treating a general nervous condition called generalized anxiety disorder, may be helpful to some alcoholics, especially those with high levels of anxiety symp toms that persist after abstinence (Kranz ler et al. 1994). However, not all studies agree on this point.
Fortunately, several important on going studies will help answer some remaining questions regarding the treatment of coexisting depressive or anxiety disorders in the context of al coholism. The COGA investigation will gather more data regarding poten tial alcoholic subtypes and will contin ue to explore possible genetic linkages between alcohol dependence and major depressive and major anxiety disorders. Certain ongoing treatment studies also are further evaluating the potential use fulness of buspirone, some specific anti depressants, and other medications that affect brain chemicals as potential com ponents for treating alcoholism. Each of these studies is taking steps to eval uate the importance of these psychi atric medications while considering whether subjects' depressive or anxi ety syndromes are likely to be alcohol induced or may indicate longer term independent psychiatric disorders. ■